Anxiety Disorders - An Introduction

Dr M.U.P.K.Peris MBBS MD MRCPsych

Senior Lecturer in Psychiatry Head - Department of Psychiatry Faculty of Medicine University of Kelaniya Ragama 05.08.11

Overview of this lecture

Prerequisites Objectives Introduction /Clinical Features Aetiology Course and prognosis Management Summary

Prerequisite Knowledge
Students to be aware of basic phenomenology in Psychiatry Familiar with concepts of history taking and mental state examination

Objectives
1. Describe what is Anxiety and outline disorders in which the anxiety presents as a primary symptom. 2.Outline the broad array of therapeutic approaches, including patient education, psychotherapy and pharmacotherapy, where appropriate in the management of Anxiety Disorders

Introduction
What is Anxiety? What is the significance of it to us?

What is Anxiety
Apprehension, tension, or uneasiness that stems from the anticipation of danger or an inability to cope, which may be internal or external...The manifestations of anxiety and fear are the same and include motor tension, autonomic hyperactivity, apprehensive expectation, and vigilance and scanning.

 Anxiety is a complex, multidimensional experience, not a simple unidimensional phenomenon. Anxiety can be understood as having three separate dimensions (Lang, 1970):
i) Verbal reports of subjective experiences (eg: tension, apprehension, sense of impending danger, expectations of an inability to cope in the future). ii) Behavioral responses (eg: avoidance, impaired speech and motor coordination, performance deficits). iii) Physiological responses (eg: muscle tension, increased heart rate, elevated blood pressure, rapid respiration, dryness of the mouth, nausea).

Back

 Psychological and Physical manifestations.

Psychological/behavioural
presence of fear and may try to resort to behaviours that would reduce it. Irritability reduced concentration and problem solving Sensitivity to noise feeling restless, unhappy, guilt repetitive worrying thoughts disturbed sleep

 Psychological and Physical manifestations.

Physical
Sympathetic overactivity - tachycardia, palpitations, sweating, dilated pupils, dryness of mouth Increased muscle tension Tachypnoea GIT symptoms- difficulty in swallowing, epigastric discomfort, borborygmi, frequest opening of bowels CNS - tinnitus, blurred vision, dizziness, head ache GUT - frequent micturition, increased urgency Long term effects - GI ulcers, reduced immunity, even malignancy

Psychobiology of Anxiety
Threat Information enters the brain Pathway

Cortex

Limbic System (Center of emotions) Amygdala (Recognizes threat)

Psychobiology of Anxiety (continued)

Hypotalamus Pituitary gland

Adrenal Cortex (cortisol) Sympatho-Adrenal Medulla (epinephrine, norepinephrine)

Fight or flight

COPING WITH STRESS AND ANXIETY

EFFECTIVE MEDIATION
Anxiety = Return to usual coping

STRESS
Psychological Physical Social

ANXIETY

RELIEF BEHAVIORS Defense Mechanisms Coping Mechanisms Social/Cultural/Spiritual Support systems

INEFFECTIVE MEDIATION
Physical Psychological Illness

Anxiety =

What is the role of anxiety in life?

Crucial for the existence of the mankind.

Performance

Anxiety

When it becomes pathological?

Anxiety is abnormal when it is persistent and coupled with no objective danger or threat, leading to ineffective and selfdefeating behaviour.

Anxiety is pathological if:

When, The response is disproportionate to the severity of the threat. The response continues beyond the existence of the threat. Functioning is impaired.

Specific Mental Illness As an associated feature of psychological Ill health Part or a response to a physical illness

Part of day to day Experience

Classification of Anxiety Disorders

Anxiety Disorders
Generalized Anxiety Disorder Phobic anxiety Disorders
simple phobias Agoraphobia social phobia

Panic Disorder Obsessive Compulsive disorder Post Traumatic Stress Disorder Mixed anxiety and depressive disorder Acute reaction to stress Adjustment Disorders

Clinical Features Generalised Anxiety Disorder

All the features of anxiety Free floating Prevalence 50:1000. Slightly commoner in females

Diagnostic guidelines The sufferer must have primary symptoms of anxiety most days for at least several weeks at a time,and usually for several months. These symptoms should usually involve elements of: (a)apprehension (worries about future misfortunes, feeling "on edge", difficulty in concentrating, etc.); (b)motor tension (restless fidgeting, tension headaches, trembling, inability to relax); and (c)autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric discomfort, dizziness, dry mouth, etc.). In children, frequent need for reassurance and recurrent somatic complaints may be prominent.

Clinical Features
Phobic Anxiety Disorder
To say it is a phobia, there must be a
fear that occurs in specific situations fear that is involuntary fear that is disproportionate to the situation behaviour that includes an avoidance of the feared situation.

Clinical Features
Phobic anxiety Disorder
Specific isolated phobia ( simple phobia)
Fear in the presence of an object or situation. Avoidance of such situation
Early in life, many dissipates away, many will not seek help

Childhood- adult life Prevalence 100:1000

Diagnostic guidelines All of the following should be fulfilled for a definite diagnosis: (a)the psychological or autonomic symptoms must be primary manifestations of anxiety, and not secondary to other symptoms such as delusion or obsessional thought; (b)the anxiety must be restricted to the presence of the particular phobic object or situation; and (c)the phobic situation is avoided whenever possible.

Clinical Features
Phobic anxiety Disorder
- Social phobia
Fear of situations in which the person is observed or criticized. Anticipatory anxiety preoccupied with an idea of being observed critically Avoidance Diagnostic guidelines All of the following criteria should be fulfilled for a definite diagnosis: (a)the psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts; (b)the anxiety must be restricted to or predominate in particular social situations; and (c)the phobic situation is avoided whenever possible.

Mid teens - late twenties Prevalence 25:1000 Equal in men and women

Clinical Features
Agoraphobia
fear in situations(at least in two situations) where they cannot leave easily or no help is available Avoidance of such situations psychological/physical symptoms are primary. Fear of loss of control other symptoms such as depression, obsessional thoughts are also well known to occur

Diagnostic guidelines All of the following criteria should be fulfilled for a definite diagnosis: (a)the psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms, such as delusions or obsessional thoughts; (b)the anxiety must be restricted to (or occur mainly in) at least two of the following situations: crowds, public places, travelling away from home, and travelling alone; and (c)avoidance of the phobic situation must be, or have been, a prominent feature.

Mid twenties to late forties Prevalence 30:1000 Twice common in women

Clinical Features
Panic Disorder
Episodic fear comes unexpectedly. overwhelming and a sense of choking or death by a serious consequence such as a heart attack. Symptoms reach a peak within 10 minutes and subsides within 30 minutes max. Fear of fear Tendency to seek Cardiologists, and
Other physicians. Prevalece 10:1000 Twice commoner in women

Clinical Features
Diagnostic guidelines In this classification, a panic attack that occurs in an established phobic situation is regarded as an expression of the severity of the phobia, which should be given diagnostic precedence. Panic disorder should be the main diagnosis only in the absence of any of the phobias in F40.-. For a definite diagnosis, several severe attacks of autonomic anxiety should have occurred within a period of about 1 month: (a)in circumstances where there is no objective danger; (b)without being confined to known or predictable situations; and (c)with comparative freedom from anxiety symptoms between attacks (although anticipatory anxiety Tendency to seek Cardiologists, and is common). Other physicians. Prevalece 10:1000 Twice commoner in women

Clinical Features
Obsessive-Compulsive Disorder (OCD)
Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment.

Clinical Features
Obsessive-Compulsive Disorder (OCD) (cont.) Thoughts Images ruminations impulses rituals primary obessional slowness

Clinical Features
Obsessive-Compulsive Disorder (OCD) (cont.)
Obsessions: Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress. Compulsions: Unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification. Rituals: Repetitive actions that a person must do over and over until the person is exhausted or anxiety is decreased.

Clinical Features
Obsessive-Compulsive Disorder (OCD) (cont.)
Diagnostic guidelines For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following characteristics: (a)they must be recognized as the individual's own thoughts or impulses; (b)there must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists; (c)the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense); (d)the thoughts, images, or impulses must be unpleasantly repetitive.

Clinical Features
Obsessive-Compulsive Disorder (OCD) (cont.)
Obsessions and or compulsions Affecting the patients functioning Obsessions and Compulsions taking more than 1 hour per day. symptoms waxing and waning Depression is common ( 1/3 pts are depressed) Prominent anxiety

Post-traumatic Stress Disorder

Development of symptoms following exposure to an extreme traumatic stressor involving a threat to the safety of self or others. Reexperiencing the traumatic event, a sustained high level of anxiety or arousal, general numbing of responsiveness. Intrusive recollections or nightmares of the event are common.

Post-traumatic Stress Disorder

Diagnostic guidelines This disorder should not generally be diagnosed unless there is evidence that it arose within 6 months of a traumatic event of exceptional severity. A "probable" diagnosis might still be possible if the delay between the event and the onset was longer than 6 months, provided that the clinical manifestations are typical and no alternative identification of the disorder (e.g. as an anxiety or obsessive-compulsive disorder or depressive episode) is plausible. In addition to evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams. Conspicuous emotional detachment, numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma are often present but are not essential for the diagnosis. The autonomic disturbances, mood disorder, and behavioural abnormalities all contribute to the diagnosis but are not of prime importance.

Adjustment disorders
States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, and arising in the period of adaptation to a significant life change or to the consequences of a stressful life event (including the presence or possibility of serious physical illness). The stressor may have affected the integrity of an individual's social network (through bereavement or separation experiences) or the wider system of social supports and values (migration or refugee status). The stressor may involve only the individual or also his or her group or community.

Adjustment Disorder
Diagnostic guidelines Diagnosis depends on a careful evaluation of the relationship between: (a)form, content, and severity of symptoms; (b)previous history and personality; and (c)stressful event, situation, or life crisis. The presence of this third factor should be clearly established and there should be strong, though perhaps presumptive, evidence that the disorder would not have arisen without it. If the stressor is relatively minor, or if a temporal connection (less than 3 months) cannot be demonstrated, the disorder should be classified elsewhere, according to its presenting features.

What is the significance of this problem to us?

Because they are common
Prevalence of Anxiety and Depressive symptoms in the general public are high as 70% in some studies

PREVALENCE OF MENTAL DISORDERS Estimated general practice prevalence of mental disorder

Diagnosis

Weekly prevalence per 1000 adults aged 16-64

Mixed anxiety and depression Generalized anxiety Depressive episode All phobias Obsessive compulsive disorder Panic disorder Functional psychoses

77 31 21 11 12 8 4.4

Source: OPCS Survey of Psychiatric Morbidity Report 1. London: HMSO, 1995.

Anxiety Statistics
Anxiety Disorders One-Year Prevalence (Adults)

Per ent

bsessi e-Compulsi e isor er

Post-Traumati isor er Any Phobia

tress

Generalized Anxiety isorder

  

  

 

 

* Bas d on 7/ /

U. .

  

Pani

isor er

Any Anxiety

isor er

13.3 1.7 2.3 3.6 8.0 2.8

nsus r sid nt o ulation sti at of

Popul tion (Millions) 19.1 2.4 3.3 5.2 11.5 4.0

ti

te*

. million, ag

What is the significance of this problem to us?

Because they are common
Prevalence of Anxiety and Depressive symptoms in the general public are high as 70%

Varied Presentations
Somatic symptoms Disguised presentations - heart attacks, depression, alcohol dependence, poor school work

Recent Studies
Freedom From Fear conducted a survey among 410 attendees during National Anxiety Disorders Screening Day on May 7, 2003. The results :
An increase in physical aches and pains is directly attributed to anxiety disorders and depression 60%) of the respondents with undiagnosed medical conditions said that on days when they feel anxious or depressed, there is a moderate (41%) to severe (19%) change in their physical symptoms or aches and pains. These physical symptoms or aches and pains include backaches (13%), vague aches and pains (14%), headaches (14%), digestive pain (11%) and dizziness (8%). 50% of respondents with diagnosed medical conditions, such as arthritis, migraines, diabetes, heart and respiratory diseases, reported that on days when they feel anxious or depressed, there is a moderate (38%) to severe (12%) change in their physical symptoms or aches and pains.

Aetiology
Genetic - for GAD 15% more than the general population Learning personality factors Cognitive theories- symptoms persists because the way the patients think about their symptoms Biological mechanisms
lack of inhibitory mechanisms 5HT, NA at various parts of the brain

Physical Reaction to Anxiety

Auditory and Visual Stimuli: sights and sounds are processed first by the thalamus, which filters the incoming cues and shunts them either directly to the amygdala or to the other parts of the cortex. Olfactory and tactile stimuli: Smells and touch sensations Bypass the thalamus altogether, Taking a shortcut directly to the Amygdala. Smells, therefore, Often evoke stronger memories Or feelings than do sights or Sounds.

Physical Reaction to Anxiety

Thalamus: The hub for sights and sounds, The thalamus breaks down Incoming visual ques by size, Shape and color, and auditory Cues, by volume and Dissonance, and then signals The appropriate part of the Cortex. Cortex: It gives raw sights and sounds meanings, enabling the brain to become conscious of what it Is seeing or hearing. One region, the prefrontal cortex, may be vital to turning off the anxiety response once a threat has passed.

Physical Reaction to Anxiety

Amygdala: emotional core of the brain, the amygdala has the primary role of triggering the fear response. information that passes through the amygdala is tagged with emotional significance. Bed Nucleus of Stria Terminalis: unlike the Amygdala, which sets off an immediate burst of fear, the BNST perpetuates the fear response, causing the longer term unease typical of anxiety.

Physical Reaction to Anxiety

Locus Ceruleus: It receives signals from the amygdala and is responsible for initiating many of the classic anxiety responses: rapid heartbeat, increased blood pressure, sweating and pupil dilation. Hippocampus: This is the memory center, vital to storing the raw information coming in from the senses along with the emotional baggage attached to the data during their trip through the amygdala.

Anxiety and panic disorder are related to distinct patterns of vestibular dysfunction

Gamma-aminobutyric acid (GABA)

GABA plays a role in activating chloride ion channels. Chloride ions (- charge) come into the cell and hyperpolarize the cell. This results in calming of overall brain excitation.
(Preston et al., 2005)

(Preston et al., 2005)

Serotonin
Excitability of locus coeruleus (LC) also mediated by serotonin. Global decrease in serotonin thought to affect LC causing it to become disinhibited (i.e., more sensitive to activation) Serotonin also hypothesized to inhibit cellular reactivity in the amygdala.

(Preston et al., 2005)

 Psychological Views of Anxiety There are several major psychological theories of anxiety: psychoanalytic and psychodynamic theory, behavioral theories, and cognitive theories (Thorn et al., 1999). Psychodynamic theories have focused on symptoms as an expression of underlying conflicts (Rush et al., 1998; Thorn et al., 1999). Although there are no empirical studies to support these psychodynamic theories, they are amenable to scientific study (Kandel, 1999) and some therapists find them useful. For example, ritualistic compulsive behavior can be viewed as a result of a specific defense mechanism that serves to channel psychic energy away from conflicted or forbidden impulses

 State anxiety A temporal cross-section in the emotional stream of life of a person, consisting of tension, apprehension, nervousness, and worry and activation (arousal) of the autonomic nervous system. Trait anxiety Relatively stable individual differences in anxiety-proneness, that is, differences between individuals in the tendency to perceive stressful situations as dangerous or threatening.

Course and Prognosis

Anxiety Disorders tend to run a chronic course although the intensity of the symptoms may subside as the time pass by. Risk factors - Women, low socio-economic class, less educated, being single. However for agoraphobia the income and level of education is inversely related. Poor prognosis: severe symptoms, syncopal episodes,agitation,hysterical features, suicidal thoughts

Management
Diagnosis
History Taking Examination - Mental State and Physical Investigations - Bio, Psycho, Social

Treatment

Treatment
Depends on the diagnostic formulation Bio/Psycho/Social model Acute, short and long term interventions.

Allopathic Treatments
Medications (Drug Therapy): Behavioral Therapy Cognitive Behavioral Therapy Psychodynamic Psychotherapy

Alternative Treatments
Acupuncture Aromatherapy Breathing Exercises Exercise Meditation Nutrition and Diet Therapy Vitamins Self Love

Treatment
For all Anxiety Disorders
Psychological
Brief supportive Psychotherapy Behaviour therapy
Anxiety management Relaxation Techniques Breathing Exercises

Listening Explanation/Advice Reassurance Prestige Suggestion

Cognitive Therapy

Pharmacological Social

Psychological Treatment

Pharmacological Therapy
Anxiolytics
Benzodiazepines Non Benzodiazepines

Pharmacological Therapy
Anxiolytics
Benzodiazepines Short acting, Lorazepam,Oxasepam,Temazepam,Triazolam,Alprazolam, Clobazam. Long acting Diazepam,Chlordiazepoxide,Clonazepam AtypicalBenzidiazepines Z series Non Benzodiazepines Buspirone, Citalopram, Venlafaxine, duloxatine, Paroxetine TCA Beta-Adrenaergic Blockers

Benzodiazepines
First drug of this type (Librium) created in 1957. Mechanism: Interact with benzodiazepine receptors and enhance the effect of GABA, increasing influx of chloride ions. Rapid effect within 30 minutes; Therapeutic effect within 1 week Relatively short half-lives (see table on p. 190 of Preston et al., 2005) 75% of users show moderate to marked improvement in symptoms Mild and transient side effects May become physically addictive and lead to withdrawal symptoms if discontinued abruptly.

(Arikian & Gorman, 2001; Preston et al., 2005; Walsh, 1999)

Atypical Benzodiazepines
Benzodiazepine derivatives used as hypnotics.
1. 2. 3. 4. Estazolam (ProSom) Quazepam (Doral) Zolpidem (Ambien) Zaleplon (Sonata)

Mechanism: Similar to benzodiazepines.

(Preston et al., 2005)

Anti-anxiety Medications (i.e., anxiolytics)

Benzodiazepines Atypical benzodiazepines Busipirone Antidepressants Antihistamines Beta blockers Clonidine Tiagabine

Buspirone
Type: azapirone drug Mechanism: Acts on 5-HT 1A receptor; thought to balance serotonin levels by lowering them in anxious persons. However, exact mechanism unknown. Delayed effect Therapeutic effect within one or two weeks. Appears particularly effective in treatment of GAD. Not addictive. Does not produce psychomotor impairment and does not interact with other CNS depressants.

(Arikian & Gorman, 2001; Preston et al., 2005; Walsh, 1999)

Other Anti-Anxiety Agents

Clonidine
Mechanism: alpha-2 adrenergic agonist; presynaptic inhibitor of norepinephrine release Originally used to treat hypertension

Tiagabine
Mechanism: GABA reuptake inhibitor Originally an anticonvulsant May be useful in treating PTSD and PD.

(Preston et al., 2005)

From www.healthyplace.com/Communities/Anxiety/treatment/medications.asp